STUDENT PROFILE & DECISION
REFERRAL STATUS - (CHECK APPROPRIATE BOX) / JP 1/4
Revised 3/2016
Academic/Behavior Intervention Team (ABIT) / Mandated Re-evaluation/Disabled Student / Create
Specially Requested Re-Eval by IEP Team / Initial Evaluation / Update
Supplemental Request by IEP Team / Change

JEFFERSON PARISH PUBLIC SCHOOL SYSTEM

Student Name / «Last_name», «First_name» / DOB / «DOB» / Student # / «St_id»
School / «School» / Grade / «gr» / Ethnicity / «eth» / Gender
Has student previously received an Individual Evaluation? / NO / YES / If YES, Date of Eval / «eval_date»
Primary Exceptionality / «P_exc» / Secondary Exceptionality / «Sec_exc»
Is student currently receiving Special Education services? / NO / YES / If YES, Date of most recent IEP
If YES, List Direct and Related Services from IEP
Home Language / ELL Services / NO / YES / Student’s dominant language
COMMENTS
PARENT/GUARDIAN/SURROGATE INFORMATION
Name / «Pname»
Address / «Address» / City / , LA / ZIP
Phone / (C) / «Cell_Number» / (H) / «Ph_Number» / (W) / (Emer)
Email
REASON FOR REFERRAL (refer to JP 2/3 for Screening & Intervention Summaries)
Reading Difficulties / Communication Difficulties / Health Problems / Court Ordered Referral (ABIT)
Mathematic Difficulties / Visual Difficulties / Gifted / Court Ordered Evaluation
Other Academic Difficulties / Hearing Difficulties / Talented / Other (Specify)
Social/Behavior Problems / Motor Difficulties / Parent Request
ACTION / Entry Date / Revision Date
Comments:
ABIT Decision / IEP Team Decision
No further action at this time / Recommend Individual Evaluation / Specially Requested ReEval
Begin Tier 2 Intervention / Section 504 Eligibility Evaluation / Change of Classification ReEval (COC)
Begin Tier 3 Intervention / FBA and/or BIP / Supplemental Evaluation
Data suggest adequate progress; Continue Tier 2 / 3 / Refer to Outside Agency (name): / Appropriate Placement (RAP)
FBA and/or BIP
Other / Other
SIGNATURES / Decision Date
Chair / ODR / Referring Teacher
Team Member / Team Member (Reg.Ed)
SPOE (Ed Diag, SWEC, or School Psych) –
REQUIRED for IE, COC, Supplemental Requests
Parent/Guardian/Surrogate / Student (if age of majority)
FORM COMPLETED BY
COPIES TO: / Special Ed Data Entry / Pupil Appraisal / Area Office / Parent / Cum Folder